Provider Demographics
NPI:1023276656
Name:PEDIATRIC DENTAL ASSOCIATES LTD
Entity type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-743-3700
Mailing Address - Street 1:6404 ROOSEVELT BLVD
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2943
Mailing Address - Country:US
Mailing Address - Phone:215-743-3700
Mailing Address - Fax:215-743-3715
Practice Address - Street 1:6404 ROOSEVELT BLVD
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2943
Practice Address - Country:US
Practice Address - Phone:215-743-3700
Practice Address - Fax:215-743-3715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025205L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty